INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 27, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Guidance For Growing, LLC was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records, the facility failed to ensure that each counselor completed at least 25 clock hours of training during the facility's August 2019 through August 2020 training year in one of one personnel record reviewed.
Employee #1 was hired as a counselor on September 1, 2008. The personnel record documented 18.5 hours of training for the training year reviewed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The executive director will review personnel records halfway through the training year (December, starting 12/21) to evaluate the employee's training hours to date. In the event the employee has less than half the required training hours, the executive director will review the training plan with the employee to explore barrier to trainings. In the event of a pandemic (which was the case during this inspection year), the director will explore online options for training. |
705.28 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on a physical plant inspection, the facility failed to ensure that the two fire extinguishers located in the hallway were inspected annually, as both extinguishers were last inspected in July 2019.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The executive director will inspect the fire extinguishers on a bi-annual basis (December and June) to determine the expiration date of the fire extinguishers. In the event the fire extinguishers are within 6-months of expiration, the executive director will notify the building manager for replacement. The executive director will notify the building owner (6/29/2021) to notify him of out-of-date fire extinguishers that need to be replaced. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of client records, the facility failed to document on consent to release information forms that a copy of the form was offered to the client in one of three client records reviewed.
Client #2 was admitted on March 31, 2020 and was discharged on May 26, 2020. A release of information form to another provider, was signed and dated by the client on June 15, 2020, did not indicate that a copy was offered to the client.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The executive director, when reviewing files, will check all release of information forms for whether or not the therapist checked off if the client accepted or rejected a copy of the release. In the event both boxes are blank, the executive director will direct the therapist to offer the client a copy during their next visit. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of client records, the facility failed to develop and document the individual's comprehensive treatment and rehabilitation plan with the client in one of three client records reviewed.
Client #1 was admitted on March 17, 2020 and was discharged on May 5, 2020. The comprehensive treatment plan was signed and dated March 24, 2020 by facility staff; however, there was no client signature or written documentation that the plan was developed with the client's input in the record at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
In the event where remote services are offered to clients (upon approval of the DDAP), the therapist will be responsible developing the treatment with the client and documenting the process in the client's DAP notes. The therapist will mail a copy of the treatment plan to the client for a signature. The development of the treatment plan will be documented by the therapist in the DAP notes. The mailing will include a return self-addressed stamped envelope for the client. An extra copy will be sent for the client's records. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to provide treatment plan updates within the regulatory timeframe in one of three client records reviewed.
Client #3 was admitted on June 15, 2020 and was discharged August 24, 2020. The comprehensive treatment plan was completed on June 22, 2020 and an update was due no later than August 22, 2020. However, the update was not completed prior to discharge.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
In the event that a client is unsuccessfully discharged and the discharge is after the 60 day treatment period, the treating therapist will still be responsible for completing a treatment plan update. This information will be conveyed to all therapist outlining that even if a client is unavailable for the treatment plan update, it is still required for the client's records. |